Adenosine
Indications
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First drug for most forms of stable narrow-complex SVT. Effective in terminating those due to reentry involving AV node or sinus node.
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May consider for unstable narrow-complex reentry tachycardia while preparations are made for cardioversion.
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Regular and monomorphic wide-complex tachycardia, though to be or previously defined to be reentry SVT.
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Does not convert atrial fibrillation, atrial flutter, or VT.
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Diagnostic maneuver: Stable narrow-complex SVT.
Precautions/Contraindications
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Contraindicated in poison/drug-induced tachycardia or second- or third-degree heart block.
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Transient side effects include flushing, chest pain or tightness, brief periods of asystole or bradycardia, ventricular ectopy.
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Less effective (larger doses may be required) in patients taking theophylline or caffeine.
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Reduce initial dose to 3 mg in patients receiving dipyridamole or carbamazepine, in heart transplant patients, or if given by central venous access.
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If administered for irregular, polymorphic wide-complex tachycardia/VT, may cause deterioration (including hypotension).
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Transient periods of sinus bradycardia and ventricular ectopy are common after termination of SVT.
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Safe and effective in pregnancy.
Dose
IV Rapid Push
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Place patient in mild reverse Trendelenburg position before administration of drug.
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Initial bolus of 6 mg given rapidly over 1 to 3 seconds followed by NS bolus of 20 ml; then elevate the extremity.
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A second dose (12 mg) can be given in 1 to 2 minutes if needed.
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Injection Technique
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Record rhythm strip during administration.
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Draw up adenosine dose in one syringe and flush in another. Attach both syringes to the same or immediately adjacent IV injection ports nearest patient, with adenosine closest to patient. Clamp IV tubing above injection port.
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Push IV adenosine as quickly as possible (1 to 3 seconds).
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While maintaining pressure on adenosine plunger, push NS flush as rapidly as possible after adenosine.
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Unclamp IV tubing.
Amiodarone
Indications
Because its use is associated with toxicity, amiodarone is indicated for use in patients with life-threatening arrhythmias when administered with appropriate monitoring.
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VF/pulseless VT unresponsive to shock delivery, CPR, and a vasopressor
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Recurrent, hemodynamically unstable VT
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With expert consultation, amiodarone may be used for treatment of some atrial and ventricular arrhythmias.
Precautions/Contraindications
Caution: Multiple complex drug interactions
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Rapid infusion may lead to hypotension
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With multiple dosing, cumulative doses >2.2g over 24 hours are associated with significant hypotension in clinical trials
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Do not administer with other drugs that prolong QT interval (eg, procainamide)
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Terminal elimination is extremely long (half-life lasts up to 40 days)
Dose
VF/pVT Cardiac Arrest Unresponsive to CPR, Shock, and Vasopressor
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First Dose: 300 mg IV/IO push
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Second Dose (if needed): 150 mg IV/IO push
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Life-Threatening Arrhythmias
Maximum Cumulative Dose: 2.2 g IV given over 24 hours. May be administered as follows:
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Rapid infusion: 150 mg IV over first 10 minutes (15 mg per minute). May repeat rapid infusion (150 mg IV) every 10 minutes as needed.
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Slow infusion: 360 mg IV over 6 hours (1 mg per minute).
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Maintenance infusion: 540 mg over 18 hours (0.5 mg per minute).
Atropine Sulfate
Can be given via endotracheal tube
Indications
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First drug for symptomatic sinus bradycardia
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May be beneficial in presence of AV nodal block. Not likely to be effective for type II second-degree or third-degree AV block or a block in nonmodal tissue
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Routine use during PEA or asystole is unlikely to have a therapeutic benefit
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Organophosphate (eg, nerve agent) poisoning: extremely large doses may be needed
Dose
Bradycardia (with or without ACS)
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0.5 mg IV every 3 to 5 minutes as needed, not to exceed total dose of 0.04 mg/kg (total 3 mg)
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Use shorter dosing interval (3 minutes) and higher doses in severe clinical conditions
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Organophosphate Poisoning
Extremely large doses (2 to 4 mg or higher) may be needed
Precautions/Contraindications
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Use with caution in presence of myocardial ischemia and hypoxia. Increases myocardial oxygen demand
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Avoid in hypothermic bradycardia
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May not be effective for infranodal (type II) AV block and new third-degree block with wide QRS complexes. (In these patients, may cause paradoxical slowing. Be prepared to pace or give catecholamines)
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Doses of atropine <0.5 mg may result in paradoxical slowing of heart rate
Dopamine
Indications
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Second-line drug of choice for symptomatic bradycardia (after atropine)
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Use for hypotension (SBP ≤70 to 100 mm Hg) with signs and symptoms of shock
Precautions/Contraindications
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Correct hypovolemia with volume replacement before initiating dopamine
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Use with caution in cardiogenic shock with accompanying CHF
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May cause tachyarrhythmias, excessive vasoconstriction
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Do not mix with sodium bicarbonate
Dose
IV administration
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Usual infusion rate is 2 to 20 mcg/kg per minute
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Titrate to patient response; taper slowly
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Epinephrine
Can be given via endotracheal tube
Available in 1:10,000 and 1:1,000 concentrations
Indications
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Cardiac arrest: VF, pulseless VT, asystole, PEA
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Symptomatic bradycardia: Can be considered after atropine as an alternative infusion to dopamine
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Sever hypotension: Can be used when pacing and atropine fails, when hypotension accompanies bradycardia, or with phosphodiesterase enzyme inhibitor
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Anaphylaxis, severe allergic reactions: Combine with large fluid volume, corticosteroids, antihistamines
Precautions/Contraindications
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Raising blood pressure and increasing heart rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand
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High doses do not improve survival or neurological outcome and may contribute to postresuscitation myocardial dysfunction
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Higher doses may be required to treat poison / drug-induced shock
Dose
Cardiac Arrest
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IV/IO dose: 1 mg (10 mL of 1:10,000 solution) administered every 3 to 5 minutes during resuscitation. Follow each dose with 20 mL flush, elevate arm for 10 to 20 seconds after dose
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Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specific indications (β-blocker or calcium channel blocker overdose)
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Continuous infusion: Initial rate: 0.1 to 0.5 mcg/kg per minute (for 70-kg patient: 7 to 35 mcg per minute); titrate to response
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Endotracheal route: 2 to 2.5 mg diluted in 10 mL NS
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Profound Bradycardia or Hypotension
2 to 10 mcg per minute infusion; titrate to patient response
Lidocaine
Can be given via endotracheal tube
Indications
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Alternative to amiodarone in cardiac arrest from VF/pVT
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Stable monomorphic VT with preserved ventricular function
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Stable polymorphic VT with normal baseline QT interval and preserved LV function when ischemia is treated and electrolyte balance is corrected
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Can be used for stable polymorphic VT with baseline QT-interval prolongation if torsades suspected
Precautions/Contraindications
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Contraindication: Prophylactic use in AMI is contraindicated
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Reduce maintenance dose (not loading dose) in presence of impaired liver function or LV dysfunction
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Discontinue infusion immediately if signs of toxicity develop
Dose
Cardiac Arrest from VF/pVT
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Initial dose: 1 to 1.5 mg/kg IV/IO
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For refractory VF, may give additional 0.5 to 0.75 mg/kg IV push, repeat in 5 to 10 minutes; maximum 3 doses or total of 3 mg/kg
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Perfusing Arrhythmia
For stable VT, wide-complex tachycardia of uncertain type, significant ectopy:
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Doses ranging from 0.5 to 0.75 mg/kg and up to 1 to 1.5 mg/kg may be used
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Repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes; maximum total dose: 3 mg/kg
Maintenance Infusion
1 to 4 mcg per minute (30 to 50 mcg/kg per minute)
Magnesium Sulfate
Indications
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Recommended for use in cardiac arrest only if torsades de pointes or suspected hypomagnesemia is present
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Life-threatening ventricular arrhythmias due to digitalis toxicity
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Routine administration in hospitalized patients with AMI is not recommended
Precautions/Contraindications
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Occasional fall in blood pressure with rapid administration
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Use with caution if renal failure is present
Dose
Cardiac Arrest (due to hypomagnesemia or torsades de pointes)
1 to 2 g (2 to 4 mL of a 50% solution diluted in 10 mL [eg, D5W, normal saline] given IV/IO)
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Torsades de Pointes with a Pulse or AMI with Hypomagnesemia
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Loading dose of 1 to 2 g mixed in 50 to 100 mL of diluent (eg, D5W, normal saline) over 5 to 60 minutes IV
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Follow with 0.5 to 1 g per hour IV (titrate to control torsades)
